260134 Breast and Cervical Cancer Screenings Application Form.docx

RFR # – Breast and Cervical Cancer Screening Services Application Response

A COMPLETE RFR RESPONSE MUST INCLUDE:

· An application response form

· Signed affirmations form

Application Form

1. Applicant Name

2. Please specify your eligibility type.

☐ Community Health Center ☐ Accountable Care Organization ☐ Hospital ☐ Health System ☐ Mammography facility ☐ Gynecology Practice ☐ Mobile clinic (e.g., mobile mammography van)

3. Please specify the type of clinical services you will provide (check all that apply):

☐ Breast cancer screening and/or diagnostic services ☐ Cervical cancer screening and/or diagnostic services

4. According to the eligibility requirements (Section C1, ) outlined in RFR #260134 are you eligible for consideration?

☐ Yes ☐ No

5. Does your agency have staff who can be trained to perform data entry in REDCap including client information, clinical services, error resolution, and billing in accordance with the requirements of the Massachusetts Breast and Cervical Cancer Program?

☐ Yes ☐ No

6. Health care organizations that participate as a breast and cervical cancer screening provider under the Massachusetts Breast and Cervical Cancer Program (MBCCP) are listed in the MBCCP webpage as a screening site. Do you agree to being listed on the MBCCP webpage and other potential promotional materials (e.g., MBCCP flyer) and to assist people in being screened through the MBCCP?

☐ Yes ☐ No

7. Please complete the following affirmations form:

Massachusetts Breast and Cervical Cancer Program

AFFIRMATIONS FORM

Initial 1

1. Our institution agrees to participate as a clinical service provider in the Massachusetts Breast and Cervical Cancer Program (MBCCP), and affirms to:

a. Assessing program eligibility of patients.

b. Obtaining informed consent from patients for participation in the program.

c. Conducting a high-risk assessment to determine if a patient is at high risk for breast and cervical cancer.

d. Redetermining program eligibility at the time of service.

e. Providing appropriate screening and diagnostic tests based on evidence-based age-appropriate guidelines.

f. Assuring timely diagnostic follow-up clinical services related to abnormal screenings through direct care or referral.

g. Referring patients diagnosed with breast or cervical cancer to free or low-cost treatment programs, including the Massachusetts Breast & Cervical Cancer Treatment Program.

h. Rescreening enrolled patients based on evidence-based guidelines and re-determining eligibility for paid services annually.

i. Prioritizing screening for populations that experience inequities in breast and cervical cancer outcomes (i.e., Black, Latinx, Asian, and Foreign-born Muslim individuals and people residing within a rural area).

Initial 2

2. Our institution affirms that we have the applicable licenses, certifications, and other documentation necessary to provide clinical services as required by federal and state laws and if there are any changes, we will notify MDPH within 24 hours of any action against your licenses or certifications. This includes:

a. Assuring that all facilities conducting mammography are MQSA certified.

b. Assuring all laboratories are CLIA certified.

Initial 3

3. Our institution affirms that we will use the Massachusetts Department of Public Health as a payor of last resort and will not invoice for services if the enrolled patient is eligible for reimbursement through other sources of funding (e.g., public or private third party).

Initial 4

4. Our institution affirms that we will seek reimbursement from the Massachusetts Department of Public Health only for services that are authorized by the MA Breast and Cervical Cancer Program. A list of authorized services is available in Attachment A: MBCCP Covered Services and CPT Codes.

Initial 5

5. Our institution affirms that we will provide all MA Breast and Cervical Cancer Program covered services at no cost to the enrolled patient and will accept the MDPH Medicare reimbursement rate as payment in full. Patients will not be balance billed for MBCCP covered services.

Initial 6

6. Our institution affirms to providing the following services:

a. Patient navigation to patients that need it, including assessing and addressing the barriers that prevent patients from obtaining breast and cervical cancer screening and follow-up services, such as assistance with scheduling an appointment and connecting patients with transportation assistance.

b. Case management services to patients that have abnormal screening results, such as helping patients obtain timely diagnostic and treatment services.

Initial 7

7. Our institution affirms to submitting clinical service and billing data monthly in MDPH RedCap (by the 15th of every month for the previous month’s services). Required data are listed in Attachment D: Current Reporting Data Elements for the MBCCP.

Initial 8

8. Our institution affirms to submitting invoices monthly (by 15th of every month for the previous month’s services), and only after the clinical and billing data has been submitted and approved by MDPH.

Initial 9

9. Our institution affirms to reimbursing MDPH for any duplicate payments, overpayment, payment of services reimbursed by another third-party payer, or other incorrect payment.

Initial 10

10. The institution affirms to keep strictly confidential all information concerning the identity of the participants of the MBCCP program and to comply with all applicable provisions of state and federal law, including the Health Insurance Portability and Accountability Act.

Initial 11

11. Our institution understands that these affirmations may be revised at any point during the contract duration. In the event of revisions, we will review and sign the most recent iteration of these affirmations to maintain and active role in the MA Breast and Cervical Cancer Program.

☐ I affirm that I will comply with the Request for Response requirements and with the terms of the affirmations.

Name (please print) Signature

Title Data (MM/DD/Year)

Agency

By submitting this application and affirmations form, you have attested that the information included in this application is accurate.